El Salvador- Make a Smile Every Day

The country of El Salvador may be small (7 million people), but it packs a big punch.  It is the size of New Jersey, and is tucked next to Guatemala, with Honduras above, and Nicaragua to the south.  They call it the "Land of the Volcanoes" for a reason, and this morning we found out why.  We flew to shore by helicopter and were able to see with our own eyes the breathtaking views of volcanoes making up this country on the "Ring of Fire."  I was all smiles as I snapped photos out the window, the rotor blades whishing overheard.   Islands of volcanic rock (now overgrown with vegetation) were scattered below, while the main coast lay ahead 

with billowing volcanic mountain peaks shrouded in the early morning mist.   My fellow doctor and mentor, LT Jacobson, nudged me and pointed earnestly at the approaching town below- La Union.   La Union is one of El Salvador's oldest seaside villages, has one of their newest ports, and is host to their Navy.  After setting down in the parking lot of the Port, we boarded a relatively large and nice commercial bus to make the transit to town.  The only problem was that the village streets of La Union were not built to handle a bus of this size.   As the driver navigated one corner turn we almost took out a woman selling food at her sidewalk stand.  I looked back and she was yelling bloody murder with her hands raised up to the sky.  Poor lady.  On the side of the road little piglets trotted along (what a peculiar sight!).  Also, I spotted several women carrying baskets of food on their head without holding on!   So cool.  Functional balance.  Hope it doesn't lead to dolor de espalda (low back pain).

The medical treatment plan for El Salvador involves a number of different sites, so today numerous teams went out to different school sites throughout La Union.  Our site was the Jose Pantojo Hijo Escuela near the town center.  As we approached the gates to enter the school, we were cheered.  Many vendors were there taking advantage of the crowds selling beverages, trinkets, and food - including a Burger King cart (who knew the King was in La Union, El Salvador?).   After we entered the site, things were a bit more under control, and LT Jacobson and I set about getting our bearings.  We saw our fearless site leaders, pediatricians CDR Bill Scouten and his deputy, MAJ Dave Hsieh, who filled us in on the lay of the land (how things were set up).  It was the first day on this site, so nothing ever goes according to planned. Mass chaos begins to take on some order after a few days.  Still, I couldn't help but be frustrated by the situation.  Our rooms were much smaller than in Tumaco, and once the Gynecologist arrived and needed my table, I found myself situated outside of the building next to a sewer drain.  There were a slew of new people working with us in El Salvador- Latter Day Saints translators as well as medical students from Virginia College of Osteopathic Medicine.  During the morning I tried my best to do it all- function without a translator, teach the medical students practical information, and in the process see as many patients as I could.  I could barely hear anything as it was, so when they started up the generator next to my workspace, I was yelling to communicate and a jackhammer started going off in my head.  I had dolor de cabeza (headache).  I stood up and walked over to a tienda de comida (food vendor) and ordered a coffee.  The 80-year-old woman behind the counter introduced herself as Esmeralda (cool name) and proceeded to tell me that she couldn't see out of her left eye.  I took a thorough history of her condition from the other side of the counter, and figured out that she had had a minor stroke. I told her that there was not much to do at this point.  "Lo Siento", I said (I'm sorry).  She nodded, and nodded again and then stared off into space.  She forgot what I was there for so I reminded her "un Café por favor.” At that point I began to worry what she was going to even put in my cup!  Have no fear, she managed, and soon I was caffeinated again.  To be honest, El Salvador coffee is not quite Juan Valdez, but it did the trick!

The most memorable person from this morning was a young boy named Antonio who came up to me as I was doing a heart exam on an elderly gentleman with congestive heart failure.  Antonio's mother was on the other side of the room receiving acupuncture and standing still as her curious child was watching me intently.  After I finished with the exam he approached me and asked what the stethoscope was for?  

I smiled and carefully put the earpieces in his ear and talked softly into the other end of the stethoscope.  Antonio jumped back in glee.  He ran across the room and put the stethoscope over the heart of his mother, and soon with his hand he made a fist and released and then made a fist again, in a heartbeat type motion.  Smart kid!  I proclaimed to him that he is officially a future doctor in El Salvador.   His mother (still with acupuncture needles all over her body) smiled proudly.

Noon came, and we got a call for lunch.  Thank goodness.  I was spent.   MRE for today is drum roll, drum roll..........Meatloaf!  I was so hungry and sweaty and tired by this point I could eat anything, even the cheese omelet MRE.   LT Jacobson, Major Hsieh, and I huddled up under the shade and shared some stories from the morning.  LT J. had a very interesting case of a 64-year-old woman with clubfeet.  Usually this condition (feet face downwards and inwards) is corrected at youth if medical support is available.  She showed me the photos of this grown woman who had persevered with this condition throughout her life.  What courage and strength!

The average worker here in La Union earns five dollars per day, and they are expected to support a family with that salary.  Can you imagine???  Based on the patients I had seen thus far today, no one, and I say no one, had health insurance.  It became obvious that for many it was a choice between healthcare or feeding their family.  One of my first patients of the afternoon was a nice 52-year-old woman named Ana Maria.  I took her into the physical therapy room away from the generator noise, and sat down to chat with her.  She told me how she has back pain, and gastritis, and also showed me a large scar on her left shoulder she received from a machete attack during the El Salvador civil war.  It had rendered her left upper extremity largely useless.  

I asked a bit more about the injury and that obviously struck a cord, because I could see her eyes instantly tear up and she described how her husband had been killed in the war, and how her two hijos (sons) had fled to the United States, and how she has not seen them since.   She was all alone.  I held her hand as she cried and allowed her to mourn and said a prayer for her.  We conversed back and forth in Spanish for quite some time, and I think more therapeutic than anything I could have done for this woman medically, was just spending time with her.  As she left she said "Hasta Manana", which means "Until Tomorrow."  I didn't have the strength to tell her I was not coming out tomorrow, but I sure hope that whomever Ana Maria does see tomorrow, they take the time to hear her story.

My biggest smile from the day came mid-afternoon when an elderly woman named Rosa came over to my area and was all in a tizzy.  She was wearing a pink embroidered pullover of sorts, completely soaked through with sweat, and was toting a large envelope full of MRI results and X-rays.  I asked her to tranquilo (relax) and to please sit down.   I took a look at her patient form and at the top right hand corner it said "Surgery."  They were screening for surgeries today, so at first I thought that this woman was in the wrong area.  As I interrogated her she revealed that she has a brain tumor and that she had been told she needed surgery as soon as possible.  My heart sank as I reached for the scans she had brought with her.   She talked a million words a minute as I looked at her films, not catching any of the details that she was telling me, except for the last part about how she didn't want to die.  On the plain X-ray I could see the mass, but on the MRIs I had a difficult time finding anything out of the ordinary.  It was time for a curbside consult of the great Dr. Biondi (radiologist).  "Siguame" (Follow me), I told the woman.   We walked through the crowds over to the rudimentary X-ray machine setup, and found Dr. Biondi munching on some MRE (I believe it was the much loathed cheese omelet).  "Only one left", he said.   I explained Rosa's case to him, and he agreed to take a look.   Rosa waited nearby with worried eyes, her granddaughter by her side.  

I told Biondi that I couldn't find the tumor.  He confirmed that neither could he, and that the X-ray looked like an osteoma (bone growth) that was nothing to be concerned about.  "Buenas Noticias!"I yelled to Rosa holding up the scans.  She looked bewildered.  You don't need surgery!  You don't have a malignant tumor in your head!  Rosa looked up to the sky and raised her arms and said "Gracias a Dios!" and proceeded to come over and give me a big hug and plant a big one on my cheek.   She was beaming from ear to ear and announced to everyone in the crowded waiting area that she did not need surgery after all.   It was great.   Pure and simple- a great moment.

The prescription I give every patient before they walk away is "Hace una sonrisa cada dia" (Make a smile every day).  As I returned to my office area, I passed by the tienda with Esmeralda, and craved another coffee.  Checked my pocket and sure enough had a quarter for one.   "Un café por favor", I said to Esmeralda.  She must not have remembered me because she asked if I was a doctor and told me the story again about how she could not see out of her left eye.  Hmmmm..........  I explained to her once again that I am Dr. Andres and that I was here earlier, and that I would try and help her after she got me a coffee.   Coffee in one hand, and Esmeralda in the other, I paid a visit to Optometry and with a bit of string pulling got her a patient form to be seen, at least evaluated.  She asked for a photo and I said only if she gives me the biggest smile possible.  She followed doctor's orders as we donned two grand "sonrisas" for a great photo to culminate a great first day in El Salvador.